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15 June 2011: Commissioning 2011

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    16 June 2011

Thank you Johnny [Marshall].

I’m not sure if it was case of extraordinary foresight on your part or if the fates are particularly interested in the modernisation of the NHS, but rarely has there been a more perfectly timed conference than this one.

For on Monday the Future Forum, under the chairmanship of Professor Steve Field who will be here this afternoon, published its report on the modernisation of the NHS.

And we have accepted all of the Future Forum’s core recommendations.

The objective of the Future Forum – made up of 45 of this country’s most eminent and experienced health and care professionals and wholly independent of government – was to look again at the detail of the proposed modernisation programme, including the proposals in the Health and Social Care Bill, and to see where it can be improved.

Not to tear it up. 

Not to start from scratch. 

Not to reject or undermine the fundamental principles of the reforms and the Bill. 

Not to prevent you, some of the most enthusiastic early adopters of modernisation, from moving ahead with your plans – making the NHS better for patients.

But legislation imposes an extra discipline.  It’s about setting the direction of the NHS for the next generation or more. 

While delay can be frustrating, especially if you have already started to put plans in place in your own communities, a pause in order to get things right, to make the Bill as good as it can possibly be is, I believe, the right thing to do.

The service can adapt and improve as we modernise and change. 
But the legislation cannot be continuously changed. 

On the contrary, it must be an enduring structure and statement. 

So it must reflect our commitment to the NHS Constitution and values. 

It must incorporate the safeguards and accountabilities that we require. 

It must protect and enhance patients’ rights and services. 

And it must be crystal clear about the duties and priorities that we will expect of all NHS bodies and in local government for the future.

The values of the NHS – high quality care, free for all, based on a person’s need and not their ability to pay – the sense of security and social solidarity it brings – are what makes the NHS special.

They are why we care so deeply about it. 

Why I care so deeply about it. 

And I will never – never – do anything to harm or undermine those essential values.

But I will also never rest while the NHS can be made better. 

The case for reform - financial

We face a situation where if we do nothing, we risk doing what we wish most to avoid – we risk damage to the NHS.

The case for change is two fold.  Financial and clinical.  Either one would be enough to make modernisation essential. 

Enormous financial pressures loom large on the horizon 

Studies suggest half of all growth in health spending is down to technological change.  Medical advances and new technology mean that procedures that were once too dangerous even to contemplate are now commonplace. 

20 years ago the risk of complications during surgery ruled out hip replacements for the over 85s.  Today they are routine. 

Over the last twenty years or so, admissions per head – the amount of care the average person receives – have increased by almost 150% for the over 85s.

Treatments evolve, lives are saved and people’s quality of life improves. 

This is great news for patients but it does have cost implications for the NHS. 

And people are living for considerably longer than they did when the NHS was first created. 

With no change, the NHS will need £130 billion by 2015.  Even with the extra £11.6 billion we are investing in the NHS, that still leaves a potential funding gap of near £20 billion.

Case for change - clinical

So there is a financial imperative to make the NHS far more efficient and far more productive.  But that is not the only reason the NHS must modernise.

The fact is, as good as the NHS can be, and it can be truly excellent, it can be much better.

Internationally, in many areas we compare poorly with others.  While cancer survival rates are improving, if they were as good as the European average, we could prevent 5,000 people from dying of cancer every year. 

And, as confirmed by the King’s Fund just last week, around 15,000 over-75s die prematurely every year in the UK when compared to the best performing countries world wide.

But it’s not only internationally that the comparisons are stark.  Depending on where you live in England, the care you receive can vary wildly.

In April, the National Cancer Intelligence Network published, for the first time, mortality rates 30 days following surgery for bowel cancer.  The average across the country was 5.8%.  But that national figure masks huge variation.  From just 1.7% at one end to 15.6% at another.

Now of course this doesn’t automatically mean that care at one place is necessarily better or worse than elsewhere.  Local differences in the age and health of the population explain some of the variation.  But not all of it.

The more data we see about the clinical outcomes of NHS care – and in the coming years we will see a lot more – the clearer the case for change becomes. 

Principles of modernisation

And change is coming.  But not just any change.  Change based on the principles we all agree are essential to the long term improvement of outcomes for patients.

First and foremost, that patients should no longer be passive recipients of care, but active participants in it. 

That they should have real choice as to how, where and by whom they are treated. 

That they should be an equal partner in decisions taken about their care. As Tuckett said, it will be a meeting of experts-clinicians and patients themselves.

That there should be no decision about me, without me.

Second, that clinicians should lead the design of services.  The clinicians I spoke to – and there were many of them – had had enough of being micro-managed from on high by politicians chasing the headlines or overly-administered by layer upon layer of suffocating bureaucracy. 

You all know...  The top-down approach just doesn’t work any more.  It smothers innovation, undermines professional judgement and leads to worse, not better care for patients.

And third, with money tight – and to be honest, even if it wasn’t – we need to focus all of our resources, all of our talent, all of our energy on the things that really matter most to patients.  We need to focus on outcomes. 

Of course, the amount of time that people wait for an operation or to be seen in A&E is important.  But I don’t think anyone believes for a moment that it is the only thing that’s important.  Waiting times will remain low – that much is guaranteed by the NHS Constitution – but we must look beyond them.

We must look at whether an operation was a success.  At survival rates.  Recovery times.  At time spent in hospital.  At whether a patient was able to retain or regain their independence.  We need to see what their overall experience of the NHS is like.

Because healthcare should be about quality as well as quantity.

The Future Forum

So a patient-centred, clinically-led, outcomes-focussed NHS is the prize. 

That is what David Cameron and I set out to achieve in 2007 when we published our first Health White Paper when in Opposition. 

It was our goal last year when we published the Health and Social Care White Paper and when we published the draft Bill.

And it remains our goal today.

But just as we need to focus on outcomes when it comes to patients, so we should focus on outcomes when it comes to drafting legislation.

While many were enthusiastic about our plans for modernisation, some did have genuine concerns. 

Some of you here may have been concerned that the detail of the Bill would not actually deliver our vision for the NHS. 

If the Bill could be improved, if there was anything that could be done to improve the NHS for patients and for the taxpayer, then it is right that we listen and act to improve it.

This isn’t something we as a government feel we need to be defensive about. 

We all want to give patients the best possible health service. 

So we invited Steve Field to lead the Future Forum and for the eight weeks he and we have been listening to the thoughts of people, the views of clinicians, of patients and of members of the public.

So just as we want to shine a light on the performance of the NHS, we have shone a bright light on the detail of the Bill and on how the proposals in the Bill would be implemented.

The Listening Exercise has really exceeded my expectations of it, especially in terms of engagement with NHS staff. 

The Forum has been an invaluable source of expert advice.  And I truly believe it has enabled us to improve the Bill, improve our proposals overall and will help us to improve the NHS.

The Future Forum Recommendations

We accept the NHS Future Forum’s core recommendations.

We will make the necessary changes to the Bill, changes that will align it even more closely with our vision for the NHS.  We will also reflect the Forum’s recommendations in how we implement the proposals in the Bill, for instance in how the NHS Commissioning Board is set up and how commissioning groups are authorised.

While the recommendations cover a wide range of topics, from research to education and training, and from the role of the Secretary of State to the NHS Constitution, I want to focus on those most relevant to you as commissioners.

The changes to GP Consortia, to governance and accountability arrangements, to competition and to the schedule for change.

Clinical Commissioning Groups

As you know full well, for commissioning to be effective it must include a wide range of people in the design of high quality local services – including a range of clinicians, patients and patient groups, carers and charities. 

So to reflect what many of you are doing on the ground, GP Consortia will from now on be known as Clinical Commissioning Groups. 

Still statutory bodies.

Still comprising GP practices coming together with a collective responsibility for their practice population and local population,

Still covering the whole country. 

Clinical Networks and Senates

To support you in commissioning, the independent NHS Commissioning Board will develop the existing clinical networks, which will be there to offer advice on how specific services, like cancer, stroke or mental health, can be better designed to provide effective care.

You know full well, no one group of doctors can design services in isolation.  The changes we are making are about making it easier for you to continue what so many of you are doing already – coming together with a wide range of colleagues within and beyond the NHS to design integrated local services.

Integration

To reflect the central importance of integrating services, Commissioning Groups will now have a duty to promote integrated health services and integrated health and social care – designed around the needs of users.

To support greater integration with council run services, Commissioning Groups will be encouraged to ensure that their boundaries do not cross those of upper tier and unitary local authorities.  Or if not to demonstrate to the NHS Commissioning Board a clear rationale for not doing so in terms of benefits to patients.

This will make it easier for you to work more closely with social care and public health commissioners, pooling budgets where needed, to improve the general health of your local population.

Governance

Because it’s public money being spent and because the health of the public is at stake, every Commissioning Group will have a governing body that will ensure that all decisions are made in an open and transparent way.

This governing body will have at least two lay members – one with a need to focus on championing public and patient involvement, the other overseeing key elements of governance, such as audit, remuneration and managing conflicts of interest.

And while we won’t prescribe in detail the wider make up of the governing body, it will need to include at least one registered nurse and one secondary care specialist doctor. 

To avoid any potential conflict of interest, neither should be employed by a local health provider.

These governing bodies will meet in public and publish their minutes, and clinical commissioning groups will need to publish details of contracts they have with health service providers.

Patient and public involvement

I have always said that I want there to be “no decision about me, without me” for patients and their own care.  The same goes for the design of local services. 

So we will further clarify the duties on the NHS Commissioning Board and Clinical Commissioning Groups to involve patients, carers and the public.  Commissioning Groups will have to consult the public on their annual commissioning plans and involve them in any changes that affect patient services.

Choice and competition

One of the main ways that patients will exercise their influence within the NHS, of course, is through their choice of provider.  This remains essential to our plans.  We will amend the Bill to strengthen and emphasis a commissioners’ duty to promote patient choice.

Of course patient choice implies competition.  And competition remains an essential means for driving up standards and quality of care.  But it has always been a means, and not an end.

We will still maintain our commitment to extend patient choice of “Any Qualified Provider”, but in a more phased way, starting from April next year.

Choice of Any Qualified Provider will be limited to those areas where there is a national or local tariff, ensuring that competition is based solely on quality and not on price – which was always our intention.

Now, there will be some areas, such as A&E or critical care, where this isn’t practicable. 

But there are others where there is already strong demand for more choice – such as community services.  This is where we will begin to introduce Any Qualified Provider.

Timetable

Finally, I want to focus on the timetable.

I know some of you have been frustrated by the pause and will be anxious to press on with your plans on the ground.

But I hope you will see the importance of taking our time to get it right.

And now, let me be absolutely clear, that there is absolutely nothing to stop you from pressing ahead.

Strategic Health Authorities and Primary Care Trusts will still cease to exist in April 2013.  By then, all GP practices will be members of either a fully or partly authorised Clinical Commissioning Group, or one in shadow form. 

We cannot have gaps in coverage, nor a two-tier system, so we will establish Clinical Commissioning Groups covering all of England by April 2013.  That is the essential building block for new accountability.

If your Commissioning Group wants to press ahead with seeking authorisation, you will be free to do so.  But we will make the timetable more flexible so that no one is forced to take on new responsibilities before they are ready.

In other words, April 2013 will not be a ‘drop dead’ date for the new commissioners.  Instead, individual Clinical Commissioning Groups will be authorised to take on budgetary responsibilities as and when they are ready to do so. And before April 2013, we will secure as much delegated responsibility as we can so that you can shadow and fully understand responsibilities.

Where a Clinical Commissioning Group is not able to take on some or all aspects of commissioning, the local arms of the NHS Commissioning Board will commission on its behalf.

Similarly for providers of care.  All NHS trusts will be required to become Foundation Trusts as soon as clinically feasible, with an agreed deadline for each trust.  But is any of the remaining NHS Trusts cannot meet Foundation Trust criteria by 2014, we will support them to achieve it subsequently. 

And when it comes to the education and training of NHS staff, we need to ensure a safe and robust transition to the new system.  It is vital that this is introduced carefully and without creating instability, and we will take the time to get it right, as the Future Forum has recommended.  And we’ll publish more detail in the autumn.

But during the transition, we will retain postgraduate deaneries, and give them a clear home within the NHS family.

Conclusion

So for those of you concerned that the listening exercise represents a tearing up of our plans to modernise the NHS, don’t be.

For those of you worried that in places the detail of the Bill was at odds with the principles of reform, be reassured.

For those of you who considered the whole listening exercise was nothing more than a PR stunt, clearly, it wasn’t.

I am proud of the work we have done these last eight weeks.

I would like to thank you for the contributions so many of you will have made these past months. 

Changing the NHS is not easy. 

But I truly believe that by working together, as we have done...

By putting the needs of patients first, as we have done...

By being clinically led, as we have been...

And by focussing on the outcomes, as we have done...

We will not only have a better Bill, we will also have a better NHS and, in time, far better outcomes for patients.

Thank you.

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